Reaccumulation Of Pleural Fluid Research Articles

Incidence of pleural effusion with dasatinib and the effect of switching therapy to a different TKI in patients with chronic phase CML

Dasatinib is one of the second generation tyrosine kinase inhibitors (TKI) which is approved for the treatment of patients with chronic phase CML (CP-CML) both in the front line and in the second line setting. Pleural effusion (PE) is a unique toxicity associated with dasatinib use. Our aim was to study the incidence of pleural effusion in our cohort of patients who were treated with dasatinib for CP-CML and the safety upon TKI switch. A total of 390 patients were treated with dasatinib during their course of treatment for CP-CML. A total of 69 patients (17.6%) developed any grade of PE. About 33 (48%) patients developed CTCAE grade 2 PE, 34 (49%) grade 3 and only 1 patient developed grade 4 PE. Recurrence of PE was observed in 34 (49%) patients. While only 12 patients (17.3%) continued using dasatinib after development of PE, dasatinib was discontinued in the other 57 patients. Therapy was switched to bosutinib in 13 patients out of which 6 (46%) patients re-developed PE. While only 12.5% patients developed re-accumulation of pleural fluid in patients switched to imatinib, none of the patients switched to nilotinib re-developed PE. A change in TKI to bosutinib was associated with a 46% risk of recurrence of PE in patients who develop PE on dasatinib for the treatment of CP-CML. The incidence of recurrent PE was markedly lower in patient switched to imatinib or nilotinib.

Assessing Factors That May Impact Physician-based Decisions for Placing Indwelling Pleural Catheters.

Malignant pleural effusion is a common finding in patients with advanced cancer and is a frequent cause of dyspnea. Current guidelines indicate thoracentesis for symptomatic patients, while indwelling pleural catheters (IPC) are recommended for patients who develop pleural fluid re-accumulation. IPC maintenance, however, requires a significant level of financial and social support. This study aims to analyze potential influencing factors that may play a role in the decision for placing IPCs in patients with recurrent malignant pleural effusions. This study retrospectively collected baseline sociodemographic and laboratory data in patients who underwent thoracentesis for malignant pleural effusion from August 2016 to October 2021, and selected patients who presented with re-accumulation of pleural fluid within 30 days or had a pulmonary physician's note documenting that IPC is a potential management option. Of these selected patients (IPC candidates), we stratified patients who underwent IPC placement and those who did not, and performed statistical analysis between these 2 groups. One hundred seventy-six patients who underwent thoracentesis were regarded as IPC candidates. Almost all baseline sociodemographic characteristics, including ethnicity ( P =0.637), sex ( P =0.655), and marital status ( P =0.773) were similar between the 2 groups, but significantly higher ECOG scores ( P =0.049) were noted in the IPC group. No statistically significant differences were noted in age, body mass index, platelet, PTT, international normalized ratio, creatinine, white blood cell, red blood cells, fluid protein, or fluid lactate dehydrogenase. Fluid albumin ( P =0.057) and serum neutrophil:lymphocyte ratio ( P =0.003) were significantly higher in patients without IPC placement. This study did not recognize any baseline sociodemographic factors that may contribute to the decision to place IPCs.

Trial Protocol: Reaccumulation rate of pleural effusions after therapeutic aspiration: An observational cohort study to determine baseline factors associated with rate of pleural fluid reaccumulation following therapeutic aspiration in patients with malignant pleural effusion attending a pleural clinic (REPEAT).

Malignant pleural effusion (MPE) is the build-up of pleural fluid in the space between the lung and chest wall due to advanced cancer. It is treated initially by large volume drainage (therapeutic aspiration). If the fluid reaccumulates, a definitive procedure is performed. There is wide variation in rate of reaccumulation. Patients with rapid reaccumulation often attend hospital as an emergency. Conversely, patients with slow reaccumulation do not need a definitive procedure and may experience cancelled or unnecessary procedures. This study aims to create and validate a multivariable prediction model to predict how quickly pleural fluid will reaccumulate in patients with MPE following therapeutic aspiration. Can we predict how quickly pleural fluid will reaccumulate in patients with MPEs? A total of 200 patients with known or suspected MPE attending for therapeutic aspiration will be recruited from 5-10 UK hospitals over 20 months. Patients will be enrolled prior to undergoing aspiration. Following this, they will undergo chest X-ray, which will be repeated one week later (treatment as usual). Rate of reaccumulation will be calculated based on change of size of the effusion seen on X-ray. Data will be collected on common clinical biomarkers e.g., size of effusion on pre-aspiration chest X-ray, volume of fluid drained. This data will be analysed to create a clinical score.A further validation cohort of 40 patients will be enrolled in parallel with creation of the score. The ability to predict rate of reaccumulation of MPE will enable patients and clinicians to make better informed treatment decisions. For patients with predicted rapid reaccumulation, a definitive procedure could be offered as first-line treatment, rather than a therapeutic aspiration. This will prevent emergency hospital admissions and decrease number of procedures. By contrast, patients whose effusions will recur slowly may avoid an unnecessary procedure.

Transthoracic sonographic scores in evaluating the success of different scelerosing modalities in patients with malignant pleural effusion

BackgroundMalignant pleural effusions (MPE) mostly arises from metastases to the pleura from other sites. Management of malignant effusions aims to palliate dyspnea and prevent the reaccumulation of pleural fluid to improve patients’ quality of life. Pleurodesis is the most common palliative treatment for patients with refractory MPE. This study was carried out to evaluate the performance of transthoracic sonographic (TUS) scores (pleural sliding and pleural adherence score) in predicting the success of pleurodesis by different modalities in patients with malignant pleural effusion. One hundred malignant pleural effusion patients were enrolled to an interventional clinical trial from September 2019 to April 2021 for palliative management of dyspnea. Pleurodesis for palliative treatment of dyspnea was done either spontaneously by the intercostal chest tube or by a sclerosing agent such as tetracycline solution or tetracycline poudrage or iodopovidine. Patients were randomly allocated to one of these four groups where each group included 25 patients. Transthoracic ultrasound was performed at baseline, and 1 month after pleurodesis and the lung sliding score and pleural adherence score were evaluated.ResultsMajority of patients (78%) had high baseline lung sliding score (7-8). Post pleurodesis only 11.4% had high scores (p<0.001), also the mean lung sliding score decreased significantly in comparison to the baseline values (p˂ 0.001) in the spontaneous, tetracycline solution, tetracycline poudrage, and iodopovidine groups (7.04 ± 1.02 vs. 4.85 ± 1.60, 7.28± 0.98 vs. 4.48± 1.75, 7.20±0.96 vs. 4.44 ± 1.45, 7.04±0.93 vs. 3.35±1.81, respectively). Iodopovidine pleurodesis group in comparison to the other modalities showed the highest pleural adherence score (12.64 ± 2.98) and absent lung sliding in 72.7% of cases and 70 % success rate. Pleural adherence score at cut off ≥ 12 showed 92.75% sensitivity, 89.47% specificity, 92.1 accuracy, and 0.911 area under the curve (AUC) for predicting successful pleurodesis.ConclusionTUS scores is a feasible, bedside, and accurate method to detect the outcome of pleurodesis. Iodopovidone was more effective than tetracycline solution, tetracycline poudrage, and spontaneous pleurodesis.Trial registrationClinicalTrials.gov. NCT04074902. Registered on 29 August 2019

Incidence of Pleural Effusion with Dasatinib and the Effect of Switching Therapy to Bosutinib in Patients with Chronic Phase CML

Incidence of Pleural Effusion with Dasatinib and the Effect of Switching Therapy to Bosutinib in Patients with Chronic Phase CML

Dietary treatment of congenital chylothorax with skimmed breast milk

BackgroundCongenital chylothorax (CC) is a rare but potentially life-threatening condition in newborns. It is defined as an accumulation of chyle in the pleural cavity. The few publications regarding medical management and therapeutic dietary intervention motivated us to share our experience.MethodsNeonates diagnosed with congenital chylothorax and treated at Innsbruck Medical University Hospital between 2013 and 2020 (n = 6, gestational age: 36 3/7, 32 5/7, 36 4/7, 35 0/7, 35 4/7, 37 3/7 weeks) were eligible for this report.The cornerstones of treatment for chylothorax conventionally consist of chest tube drainage (CTD), respiratory support, dietary restriction of long-chain triglycerides (LCT) or total parenteral nutrition (TPN). In further course the introduction of a medium-chain triglyceride (MCT)-based formula followed by an overlapping switch to a formula with low LCT and high MCT, containing the essential long-chain fatty acids (LCFA), is attempted. In three patients we used fat-modified (skimmed) breast milk to provide a high protein and low fat diet and to avoid the discontinuation of breast milk.ResultsThe outcome of an early introduction of LCFA in the form of skimmed breast milk after resolution of chylothorax diverse. One patient had a favourable outcome, meaning no recurrence of pleural effusion, adequate weight gain and a content mother, while another patient had a relapse of pleural effusion after the administration of skimmed milk and was therefore transitioned back to Basic F® .The CC of patient 5 was difficult due to Noonan syndrome. Two weeks after the introduction of skimmed breast milk the mother wanted to stop to express breast milk, so nutrition was changed to Basic F®.ConclusionThe first-line therapy of chylothorax is a combination of respiratory stabilization and dietary modification. The use of skimmed breast milk is advisable in CC and feasible by means of a simple milk defatting procedure. It offers benefits to mothers who wish to resume breast feeding after resolution of chylothorax and has proven positive effects, above all in preterm infants as optimal nutrition with protective components superior to formula feeding. However, the nutritional analysis of the skimmed milk and the correlation to a re-accumulation of pleural fluid remains a question to be answered.

Identifying Actionable Causes of Potentially Avoidable Readmissions to an Oncology Service at a Safety Net Hospital.

Hospital readmissions occur commonly in those receiving cancer care and result in impaired quality of life and increased costs. Causes of readmission in safety net hospitals that serve vulnerable populations are not well understood. The primary goal of this project was to identify potentially avoidable and intervenable causes of readmissions to an urban safety net hospital. A retrospective chart review was performed on patients who were readmitted within 30 days of discharge from the hematology and oncology service at Boston Medical Center over the 6-month period between October 2018 and March 2019. Charts were reviewed by three internal medicine residents and discussed under the supervision of an attending oncologist. Two hundred ninety-one patient encounters involving 203 unique patients were identified in the 6-month study period. Of these 291 encounters, 80 encounters (27.5%) were followed by a readmission within 30 days and occurred in 61 (30.0%) unique patients. Nineteen (31.1%) of these 61 patients experienced two readmissions within 30 days of discharge. Twenty-five readmissions (31.3%) were classified as potentially avoidable, with the most common cause of potentially avoidable readmissions attributed to ascitic or pleural fluid reaccumulation (8, 32%). The majority of presumed nonpreventable readmissions were due to expected complications of cancer progression and treatment-related side effects. In conclusion, readmissions were common, and a modifiable reason for 30-day readmissions was identified. Addressing recurrent ascitic and pleural fluid reaccumulation in the outpatient setting could help to reduce inpatient hospital readmission on an inpatient oncology service.

UNEXPECTED EFFUSION: BILOTHORAX IN PATIENT WITH METASTATIC BREAST CANCER

SESSION TITLE: Fellows Disorders of the Pleura Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Bilothorax is a rare cause of pleural effusion. It is thought to be caused by translocation of bilious fluid through a diaphragmatic defect, whether passive, congenital or iatrogenic [1,2]. It is often described as a rapidly-accumulating, right-sided pleural effusion occurring after instrumentation near to or on the biliary tree. Patients are at high risk of developing empyema and can present with signs of infection. We describe a case of a slowly-accumulating right-sided bilothorax in a patient without signs of infection. CASE PRESENTATION: A 39 y/o lady with history of triple-negative breast cancer, metastasized to the brain and spine, was referred to our clinic for dyspnea on exertion for 1 month. She had been treated with multiple lines of chemotherapy & proton beam radiation to her metastases. A staging PET/CT scan 3 months prior revealed a liver lesion that was suspicious for metastases. A CT-guided percutaneous liver biopsy was recommended. An abdominal scan incidentally caught segmental pulmonary emboli (PE), for which a chest CT was performed. Due to a post-procedural complication of hepatic sub-capsular hematoma, the patient was not anti-coagulated & had IVC filter placement instead. Her chest imaging at this time was revealing of minimal, trace bilateral effusions. She presented 1 month later for staging scans. Chest imaging at this time was significant for a trace right-sided pleural effusion. The patient did not have any respiratory symptoms. When she was seen by her oncologist for follow-up one month thereafter, she reported feeling dyspnea on exertion. At this point, a CT chest confirmed a small-to-moderate right pleural effusion. She had no fevers, cough, or constitutional symptoms except chronic fatigue and weakness which preceded her dyspnea. In our clinic, we appreciated a moderate-sized right pleural effusion on ultrasound. Given the insidious nature of her dyspnea, we postulated that her effusion was likely malignant. We performed thoracentesis for both diagnostic and therapeutic purposes. A total of 1.1L of dark green fluid was drained. Fluid studies returned with a pleural fluid to serum bilirubin ratio greater than one, confirming bilothorax. Cytology of the effusion was negative for cancer cells. Repeated chest imaging at 1 and 2 months post-thoracentesis did not reveal re-accumulation of pleural fluid, and patient’s dyspnea did not return. DISCUSSION: We describe a case of a slowly accumulating bilothorax after percutaneous CT-guided liver biopsy. Fortunately, our patient did not develop an empyema from this effusion. CONCLUSIONS: A high suspicion for bilothorax should be maintained when patients develop a novel pleural effusion within the days to months following an abdominal procedure in close proximity to the biliary tree. Prompt diagnosis and drainage lends to both symptomatic relief & prevention of further complications of infection in the pleural space. Reference #1: Jenkinson MRJ, Campbell W, Taylor MA. Bilothorax as a rare sign of intra-abdominal bile leak in a patient without peritonitis. Ann R Coll Surg Engl. 2013;95(7):e12-e13. doi:10.1308/003588413X13629960047678 Reference #2: Basu S, Bhadani S, Shukla VK. A dangerous pleural effusion. Ann R Coll Surg Engl. 2010;92(5):W53-W54. doi:10.1308/147870810X12699662980637 DISCLOSURES: No relevant relationships by Saamia Hossain, source=Web Response No relevant relationships by Robert Lee, source=Web Response

Outcome of ultrasound-guided, single session pleurodesis in malignant pleural effusion

BackgroundChemical pleurodesis is frequently indicated to relieve symptoms imposed by large/recurrent malignant pleural effusion (MPE). Traditionally, a drain is left in the pleural space till the cessation of fluid accumulation before pleurodesis. Chest ultrasound can detect an amount of pleural fluid as less as 50 ml and can confirm apposition of the pleural surfaces which is required for successful pleurodesis. This work assessed the efficiency and safety of ultrasound-guided, single-session pleurodesis in cases with MPE.ResultsSeventeen of the patients completed a 2-month follow-up. The technique demonstrated a high success rate (88.2%). The mean duration from the start of pleural drainage till pleurodesis was 1.65 ± 0.70 h ranging from 1 to 3 h. A duration of 2.5 h or less was statistically proposed as a cutoff value not to exceed to predict success (sensitivity 100%, specificity 100%). The mean time for total hospital stay related to pleurodesis was 9.88 ± 3.12 h (range 4–12 h). No complications attributed to the procedure were recorded. Pleural Adherence Score and Absent Sliding Score (ASS) had a highly statistically significant correlation (p value < 0.001).ConclusionsAn ultrasound-guided completion of the process of pleurodesis in a single session with a shorter duration of pleural fluid drainage and shorter hospital stay (can be done on a day-care basis) is efficient, safe, and cost-effective. This technique is strongly recommended to replace the traditional practice of keeping the indwelling pleural drain for several days waiting for the cessation of pleural fluid reaccumulation. An ultrasound-derived ASS can be used as early as day 1 and day 15 to confirm pleural adherence and to expect the outcome of pleurodesis.

BLINDED BY THE LIGHT: A CASE OF MALIGNANT PLEURAL EFFUSION WITH TRANSUDATIVE PROPERTIES

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Light’s criteria is routinely used to help aid in the diagnosis and treatment of pleural effusions by categorizing them into transudates or exudates. Pleural effusions due to malignancy and infection are classically exudative, while effusions from heart failure, cirrhosis, and renal failure are examples of usual transudates (1). When exceptions to this pattern do occur, it is most often that a transudate is misclassified as an exudate (1). Presented is a case where a transudative effusion was later discovered to be malignant due to likely concurrent hepatic hydrothorax. CASE PRESENTATION: A 59 year-old male with a history of alcoholic cirrhosis presented with respiratory distress and right upper quadrant pain was found to have complete opacification of the left hemithorax on chest X-ray. Upon admission, the pulmonary service was consulted where bedside evaluation confirmed a large right pleural effusion anechoic by ultrasound. Diagnostic thoracentesis was consistent with a transudative effusion with pleural protein 1.1, serum protein 5.6, pleural lactate dehydrogenase 76, and serum lactate dehydrogenase 269. Hepatic hydrothorax was considered to be the likely etiology given presence of ascites and a history of cirrhosis. Medical cytology however later revealed atypical neoplastic cells. Abdominal imaging revealed a large mass in the right hepatic lobe. IR-guided biopsy revealed metastatic adenocarcinoma with a primary cholangiocarcinoma. Prior to oncologolical evaluation for chemotherapeutic options, the patient decompensated with worsening encephalopathy and respiratory distress from re-accumulation of pleural fluid and abdominal ascites. Given overall grave prognosis, goals of care discussions were held and comfort care was initiated with the patient passing comfortably shortly thereafter. DISCUSSION: Light’s criteria are routinely used to help aid in the diagnosis and treatment of pleural effusions by categorizing them into transudates or exudates. Certain etiologies of pleural effusions are classically transudative, while others are exudative (1). When pleural studies do not meet Light’s criteria for an exudative effusion, physicians will tend to consider that malignancy and infection are ruled out (2, 3). This can lead to a missed or incorrect diagnosis since malignant effusions have been described in the literature to be transudative in as much 10.6% (4) of cases. We describe a case where pleural studies did not meet criteria for an exudative effusion, so a malignant etiology was initially considered to be unlikely. However, medical cytology later showed malignant cells, leading to further work-up revealing the primary underlying cholangiocarcinoma. CONCLUSIONS: When an effusion is transudative, one cannot assume that malignancy is ruled out, otherwise a deadly diagnosis may be missed. Reference #1: Light RW. “The Light criteria. The beginning and why they are useful 40 years later.” Clinical Chest Medicine 2013; 34(1): 21-6. Reference #2: McGrath EE, Anderson PB. “Diagnosis of pleural effusion: a systematic approach.” American Journal of Critical Care 2011; 20(2): 119-27. Reference #3: Thomas R, Cheah HM, Creaney J, Turlach BA, Lee YCG. “Longitudinal measurement of pleural fluid biochemistry and cytokines in malignant pleural effusions.” Chest 2016; 149(6): 1494-500. DISCLOSURES: no disclosure on file for Alfredo Astua; No relevant relationships by Dawn Maldonado, source=Web Response No relevant relationships by Michael Megally, source=Web Response

Hubungan Nilai PH Cairan Pleura dengan Hasil Pleurodesis pada Penderita Efusi Pleura karena Keganasan

Background: Pleural effusion is a frequent complication of advanced stage are obtained in patients with malignancy. Shortness of breath at rest and decreased exercise tolerance are major functional limitations for patients with cancer who develop extensive pleural effusion. Pleural fluid drainage followed by a pleurodesis can reduce the symptoms of shortness of breath and prevent pleural fluid reaccumulation. Unfortunately, pleurodesis attempts fail in 10 to 40% of patients with recurrent pleural fluid and shortness of breath. Low pleural fluid pH can be used as a marker for increased metabolic activity of tumors in intrapleura, and is associated with increasing tumor, and can predict the failure of pleurodesis. The purpose of this study was to prove association between low pleural fluid pH value with failure pleurodesis in patients pleural effusion malignancy. Method: This is an observational study with cross sectional design that is the analysis conducted at Hospital Dr Soetomo in patients pleural effusion malignancy were subjected to pleurodesis for 6 months. Total 11 patients who meet the inclusion and exclusion criteria. Result: The mean value obtained pleural fluid pH 7,3±0,2, based on logistic regression analysis obtained low pleural fluid pH is not significant association with failure of pleurodesis, as shown from the significant value generated wald test is 0,116 where the value is above 0,05. Conclusion: Low pleural fluid pH is not significant association with failure of pleurodesis.

Efficacy and Safety of Indwelling Pleural Catheters in Management of Hepatic Hydrothorax: A Systematic Review of Literature

Introduction: Hepatic hydrothorax (HH) is an infrequent but debilitating and therapeutically challenging complication of advanced liver cirrhosis. As evidence suggests against chest tube placement in HH many clinicians are reluctant to place indwelling pleural catheters (IPCs) for non-malignant effusions like HH as well. We aim to study the efficacy and safety of IPCs as an alternative treatment option in our systematic review. Methods: A literature search was conducted using the electronic database engines MEDLINE through PubMed, EMBASE, Ovid, Scopus and Cochrane Library (Cochrane Central Register of Controlled trialsand Cochrane Database of Systematic Reviews)from inception to April, 2018 to identify published articles and reports addressing outcomes in patients treated with an IPC for the treatment of HH [figure 1]. Risk of bias was rated for each study by using the Cochrane criteria. Results: The search strategy retrieved 370 papers out of which 4 observational studies were selected with a total of 111 patients.After insertion of IPCs for HH spontaneous pleurodesis was achieved in 16 (31.4%) out of 51 patients and mean duration to achieve spontaneous pleurodesis was 73-222 days. As far as secondary outcomes are concerned, frequency of pneumothorax during or after the procedure was 0 (0%) out of 92 patients, pain at insertion site 12 (20%) out of 60 patients, catheter blockage 2 (2.9%) out of 68 patients, pleural fluid infection 5 (4.5%) out of 111 patients and catheter site cellulitis 1 (3.1%) out of 32 patients. Re-accumulation of pleural fluid after catheter removal was mentioned in one study in which 12 (20%) out of 60 patients developed recurrence of pleural effusion. Primary and secondary end points are summarized in figure 2. Conclusion: We conclude that IPC is an acceptable therapeutic option for the management of refractory pleural effusion in patients with hepatic hydrothorax. Although TIPS and liver transplantation are gold standards for management of pleural effusion in these patients, cost and availability are major concerns with these treatment modalities. Tunneled pleural catheter is safe and efficacious alternative with a reasonable rate of spontaneous pleurodesis.969_A Figure 1. Prisma diagram showing method of study selection969_B Figure 2. showing primary and secondary end points

URINOTHORAX: A RARE CAUSE OF PLEURAL EFFUSION AFTER ELECTIVE NEPHROLITHOTOMY

SESSION TITLE: Medical Student/Resident Signs and Symptoms of Chest Diseases SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Urinothorax is a rare condition that consists of the accumulation of urine in the pleural space usually due to trauma or obstruction of the genitourinary tract[1,2]. Its rarity makes diagnosis and treatment challenging. Below, we present a case of unilateral urinothorax after elective nephrolithotomy. CASE PRESENTATION: A 54-year-old female with recurrent urinary tract infections, nephrolithiasis, and chronic kidney disease presented to the hospital for elective nephroureteral catheter placement and nephrolithotomy for a 2cm right kidney stone. On admission, a 24fr catheter was placed into the right renal pelvis. Post-procedure, she appeared well and complained of mild pain around the catheter site. Imaging confirmed satisfactory position of the catheter. The next day, she underwent right percutaneous nephrolithotomy. During the procedure, the catheter was replaced with a dual-lumen access catheter using fluoroscopy. The surgeon noted that the tract was more medial than the usual tract. The stone was treated with lithotripsy and a sterile catheter was replaced into the renal pelvis. Post-operatively, she complained of dyspnea and pain at the catheter site. She rapidly developed respiratory distress and hypoxia, requiring supplemental oxygen via a non-rebreather. Examination and imaging were consistent with a right pleural effusion. The existing nephroureteral catheter was downsized and a chest tube was inserted with drainage of 2L of serosanguinous fluid from the pleural space. The patient improved and the effusion remained stable. Two days later, she developed acute respiratory distress due to re-accumulation of pleural fluid. A nephrostogram revealed no communication between the catheter and pleural space. Pleural fluid studies demonstrated a transudate with pH 7.4, LDH 177, creatinine 2.8 (serum creatinine 1.4). Her symptoms improved over the next three days. A repeat CT showed improvement in the effusion but loculations were noted. Surgical intervention was considered but deferred. The chest tube was removed and she was discharged. She did well with resolution of the loculations and did not require surgical decortication. DISCUSSION: Given the rare (likely underdiagnosed) nature of a urinothorax, knowledge surrounding its clinical course, pleural fluid characteristics, and best treatment is lacking. A recent review concluded that most cases of urinothorax are unilateral, of traumatic (commonly surgical) origin, have a high LDH, pleural fluid/serum creatinine ratio >1.0, and/or pH <7.3[2]. Dyspnea was the primary symptom[2]. Successful treatment focused on the underlying uropathy, with or without thoracentesis[2]. Decortication was performed in a small number of patients with a favorable outcome in all[2]. CONCLUSIONS: This case demonstrates a rare complication of urologic procedures for which increased awareness and clinical suspicion may aid in its timely diagnosis and management. Reference #1: Austin A, Johani SN, Brasher PB, Argula RG, Huggins JT, Chopra A. The urinothorax: a comprehensive review with case series. Am J Med Sci. 2017;354(1):44-53. Reference #2: Toubes ME, Lama A, Ferreiro L, et al. Urinothorax: a systemic review. J Thorac Dis. 2017;9(5):1209-1218. DISCLOSURES: No relevant relationships by Stephanie Hart, source=Web Response No relevant relationships by George Lieb, source=Admin input

Efficacy and Safety of Indwelling Pleural Catheters in Management of Hepatic Hydrothorax: A Systematic Review of Literature.

Hepatic hydrothorax (HH) is an infrequent but debilitating and therapeutically challenging complication of advanced liver cirrhosis. As evidence suggests against chest tube placement in HH, many clinicians are reluctant to place indwelling pleural catheters (IPCs) for non-malignant effusions like HH. We aim to study the efficacy and safety of IPCs as an alternative treatment option in our systematic review.A literature search was conducted using the electronic database engines MEDLINE, PubMed, EMBASE, Ovid, Scopus and Cochrane Library (Cochrane Central Register of Controlled trials and Cochrane Database of Systematic Reviews) from inception to April 2018 to identify published articles and reports addressing outcomes in patients treated for HH with IPCs. The risk of bias was rated for each study using the Cochrane criteria.The search strategy retrieved 370 papers, of which four case series were selected with a total of 111 patients. After the insertion of IPCs for HH, spontaneous pleurodesis was achieved in 16 (31.4%) out of 51 patients at a mean duration of 73-222 days. As far as secondary outcomes were concerned, the frequency of pneumothorax during or after the procedure was 0 (0%) out of 92 patients, pain at insertion site 12 (20%) out of 60 patients, catheter blockage two (2.9%) out of 68 patients, pleural fluid infection five (4.5%) out of 111 patients and catheter-site cellulitis one (3.1%) out of 32 patients. Re-accumulation of pleural fluid after catheter removal was mentioned in one study, wherein 12 (20%) out of 60 patients developed recurrence of pleural effusion.We conclude IPCs as an acceptable therapeutic option for the management of refractory pleural effusion in patients with HH. Although trans-jugular intrahepatic portosystemic shunt (TIPS) and liver transplantation are the gold standards for the management of pleural effusion in these patients, cost and availability are the major concerns with these treatment modalities. IPCs are a safe and efficacious alternative with a reasonable rate of spontaneous pleurodesis.

The volume threshold of 300 versus 100 ml/day for chest tube removal after pulmonary lobectomy: a meta-analysis

In this meta-analysis, we conducted a pooled analysis of clinical studies comparing the efficacy of a volume threshold of 300 ml/day before removing a chest tube (CT) versus 100 ml/day after a lobectomy. According to the recommendations of the Cochrane Collaboration, we established a rigorous study protocol. We performed a systematic electronic search of PubMed, Embase, Cochrane Library, Web of Science databases, CNKI, the Wanfang database, CBMdisc and Google Scholar to identify articles to include in our meta-analysis. A literature search was performed using relevant keywords. A meta-analysis was performed using RevMan© software. Five studies, published between 2014 and 2015, including 615 patients (314 patients who had the CT removed when daily drainage was <300 ml and 301 patients who had the CT removed when daily drainage was <100 ml) met the selection criteria. From the available data, the patients using the volume threshold of 300 ml/day had a significantly decreased duration of drainage [MD = -44.07; 95% confidence interval (CI) -64.45 to -23.68; P < 0.0001] and hospital stay after operation (MD = -2.25; 95% CI -3.52 to -0.97; P = 0.0006) compared with patients using a volume threshold of 100 ml/day after a pulmonary lobectomy. However, no significant differences were observed in postoperative complications, such as pleural fluid reaccumulation [Odds ratio (OR) = 1.73; 95% CI = 0.74-4.07; P = 0.21] and atelectasis (OR = 0.97; 95% CI = 0.52-1.81; P = 0.93). Thoracentesis rates after removing the CT also showed no significant difference (OR = 1.53; 95% CI 0.55-4.22; P = 0.41). Our results showed that a higher volume threshold, up to 300 ml/day, is effective in reducing hospitalization times and duration of drainage in patients who undergo a lobectomy. Moreover, the volume threshold of 300 ml/day does not increase the occurrence of postoperative atelectasis, pleural fluid reaccumulation and thoracentesis rates. However, this review is limited by the methodological quality of the included trials, and additional studies according to the recommendations of Cochrane Library are appreciated.

Comparison of Efficiency of Pleurodesis Between Video Assisted Thoracoscopic Surgery (VATS) and Standard Thoracostomy.

Background:Chemical pleurodesis is generally accepted palliative dyspnea therapy and preventive of re-accumulation of pleural fluid in patients with malignant pleural effusions.Aim:Comparative analyses of efficiency of chemical pleurodesis between Video Assisted Thoracoscopic Surgery (VATS) and standard thoracostomy.Methods:From 01.01.2016-01.01.2017 at the Clinic for Thoracic Surgery of University Clinical Center (UCC) Sarajevo retrospective analysis was performed. Studied patients underwent VATS pleurodesis (G1) and standard thoracostomy pleurodesis (G2), with 60 in each group, respecting defined inclusion and exclusion criteria. Pleurodesis success was examined radiologically over the next three months.Results:Average age of all patients was 63.97±8.75 years. Gender related, 45% were men and 55% were women (F/M=1.47:1). Average hospitalization was 7.22±1.37 (G1: 6.68±1.16; G2: 7.44±1.40; Mann-Whitney U-test: p=0.0016) days. Average thoracic drainage duration was 5.45±1.69, (G1: 4.28±1.15,G2: 6.05±1.58; Mann-Whitney U-test p<0.0001) days. Pleurodesis success after first month was 98.30% in G1, 91.60% in G2 (G1 vs. G2; p=0.2089); after second month was 98.30% in G1, 78.30% in G2 (G1 vs. G2; p=0.0011) and after three months was 91.60% in G1, 63.30% in G2(G1 vs. G2; p=0.0006). Average dyspnea degree (0-5) after the pleurodesis was 0.050±0.22 in G1 and 0.62±0.76 in G2 (Mann-Whitney U-test; p=0.0001). Complication were noticed in 9.2% patients, in G1 3.3%, 15.0% in G2.Conclusion:Difference in pleurodesis efficiency between the G1 and G2 was established after second month and was even more evident after third month in favor of G1. Results show the significant statistical improvement of the degree of dyspnea in G1 as opposite to the G2.

Successful use of doxycycline pleurodesis in non-immune hydrops fetalis secondary to congenital chylothorax

Abstract Congenital chylothorax is a rare presentation of nonimmune hydrops fetalis (NIHF). We report a case of congenital chylothorax presenting as NIHF managed successfully with chemical pleurodesis. A term male infant presented at birth with anasarca and respiratory failure secondary to bilateral pleural effusions. The infant was initially managed with ventilation and tube thoracocentesis however re-accumulation of pleural fluid occurred when feeds were started. Pleural fluid analysis was consistent with congenital chylothorax. Pleural fluid re-accumulated despite conservative management with tube thoracocentesis, nutritional interventions and octreotide therapy but responded to chemical pleurodesis with doxycycline. To our knowledge, this is the first case of congenital chylothorax treated successfully with chemical pleurodesis utilizing doxycycline as the sclerosing agent. This case adds to the literature by providing support for doxycycline as an alternative agent for chemical pleurodesis in the management of congenital chylothorax.

Therapeutical effect of intrapleural perfusion with hyperthermic chemotherapy on malignant pleural effusion under video-assisted thoracoscopic surgery

Background: Patients with malignant pleural effusions (MPEs) have limited life expectancy. This study aims to investigate the feasibility of intrapleural perfusion with hyperthermic chemotherapy (IPHC) under video-assisted thoracoscopic surgery on MPE patients.Methods: MPE patients were enrolled in the study and treated with IPHC. The treatment response was classified as complete response (CR, no re-accumulation of pleural fluid for 4 weeks), partial response (PR, re-accumulation above the post-IPHC level but below the pre-IPHC level for four weeks), no response (NR; re-accumulation or above the pre-IPHC level). The change of Karnofsky performance score (KPS) and tumour markers were also recorded. Follow-up was done every two weeks during first month and monthly thereafter until death.Results: Eighty patients included 46 males and 34 females were included in the study. The total response rate was 100%, with 71.3% of CR and 28.7% of PR. The KPS scores were significantly elevated and the level of tumour markers in pleural effusion were dramatically decreased after IPHC. The median survival was 16.8 months ranged from 2.1 to 67.4 months. One-year and two-year survival rates were 82.5% and 23.8%, respectively. There were no serious clinical compilations during IPHC treatment.Conclusions: IPHC is a safety, effective and promising approach for MPE patients. It provides well survival benefit and minor toxicities.

Thoracoscopic tetracycline poudrage for pleurodesis in malignant pleural effusion

Malignant pleural effusion (MPE) is a common problem and a real challenge to pulmonologists and oncologists. The optimum management of MPE depends on several factors, including patient’s symptoms and primary tumor status. Complete drainage and pleurodesis to prevent recurrence is usually needed. Tetracycline, talc, and bleomycin are considered the primary sclerosing agents. The aim of the study was to investigate the feasibility, effectiveness, and safety of thoracoscopically insufflated tetracycline powder to achieve pleurodesis in patients with MPE. Twenty patients with recurrent pleural effusion that proved to be malignant, or showing a picture highly suggestive of pleural malignancy at thoracoscopy, were included in the study. They were subjected to tetracycline poudrage (35 mg/kg) through medical thoracoscopy. Following discharge, patients were followed up at 3 and 6 months; the primary outcome was the measure of pleurodesis failure, defined as the reaccumulation of pleural fluid requiring further pleural intervention. Of the 20 patients included in this study, five were excluded from evaluation (two because of failure of lung re-expansion and three because of death within 2 months of the procedure). The overall success rate of thoracoscopic tetracycline poudrage pleurodesis in the 15 patients with MPE who completed the study was 86.6%. There was no recorded mortality or significant complications. From this pilot study, we can conclude that thoracoscopy with tetracycline poudrage is an easy, safe, and effective method for performing pleurodesis in MPE.

Indwelling Tunneled Pleural Catheters for the Management of Hepatic Hydrothorax. A Pilot Study.

Hepatic hydrothorax is a complication of cirrhosis in which hydrostatic imbalances result in fluid accumulation within the pleural space. Although uncommon, this may cause significant morbidity, resulting in dyspnea requiring repeated pleural drainage procedures. Liver transplantation is curative, but it is rarely immediately available to qualified patients, presenting the clinical challenge of managing recurrent pleural effusions. Indwelling tunneled pleural catheters (ITPCs) have been used successfully to palliate dyspnea associated with recurrent malignant pleural effusions. This study was performed to evaluate the feasibility of using ITPCs for the management of hepatic hydrothorax. A single-center prospective feasibility study was performed to evaluate the use of ITPCs for the management of recurrent hepatic hydrothorax in patients who were eligible for liver transplant evaluation. Twenty-five ITPCs were placed in 24 patients. The mean number of pleural drainage procedures before ITPC placement was 1.9, with no further pleural drainages required in any patient after ITPC placement. Spontaneous pleurodesis occurred in 8 of 24 patients (33%). All eight catheters were successfully removed without pleural fluid reaccumulation. Mean time to pleurodesis was 131.8 days. Pleural fluid infection occurred in 4 of 24 patients (16.7%), requiring catheter removal in 3 of the 4 patients. ITPCs may be successfully and safely used to control symptoms associated with hepatic hydrothorax. The rate of spontaneous pleurodesis that occurs is similar to that observed with ITPCs placed for malignant pleural effusion, although the infection rate may be higher. Clinical trial registered with www.clinicaltrials.gov (NCT02595567).